--Game--
Game name:

--Dump--
Dump tool hardware, firmware and software version: 
Dumper: 
Affiliation: 
Dump creation date:
Dump release date:
Link(s) to release:

--ROM(s)/file(s)--
Size in bytes: 
CRC32: 
MD5: 
SHA-1: 
SHA-256:

Note: If the game is made up of a folder with subfolders, then follow this guide for getting the hashes:
https://dumping.guide/directory_dir2dat_guide

--Physical media--
Region bought in: 
Photos/scans of all sides of both physical media and packaging: 

--Etc--
Text/metadata files provided by the dump tool : p

https://wiki.no-intro.org/index.php?title=Submitting_dump_info

See here for details on about what can be derived the aforementioned information.